preaet Rare @ : ) . : f ANNEXURE-T THE FOOD CORPORATION OF INDIA . (CONTRIBUTORY PROVIDENT FUND) q : (Regulations, 1967) Name (in block letters) Surname = 2 Castes 3. Sex = 4. Religion = 5. Occupation Establishment/Department : 6 Height 2 7. Father's Name - ’ 8, Husband’s Name - (For married women employees only) ° Maral Status 10. Date of Birth : Day = Month: 9 1. Mak of Identification ae 12. Penthanent Address = 15. _LIngteby nominate the person or persons mentioned below to recive the amount standing ‘0 My credit in the Fund in the event of my death before that amount has become payable or having become payable has not been paid and direct that the said amount chall be ‘distributed among the said persons inthe manner shown below against their names. Namé and Address _[Nominee’s | Age of | Amount of Share of ofthe Nominee or | relationship _| Nominee | accumulation ‘nthe nominees swith the Fund to be paid to | the nomination shall member each nominee become invalid t | ae 2 eae 5 7e ANNEXURE 1 (Contd) » Signature or LeafvRight hand. ‘thumb impression of the mesnber $ To be completed bythe employer Cersed atthe abow declaration hasbeen signedtnimb im pressed by Shii/Shrimati.. ee - sme linmy establishneat before alter helshehas ica coieal hinvher by me and got confirmed by kewher, ‘Signature of the employer or other authorised officer of his establishment Designation . Name andaddiessof the establishment.CAE FOOD ConrorAtion or inva “ (ConTmaBUTORY PRoviDENT Font, AO ORetvisitens ine See Moe Wek ee Suman The ee ee ee 5 FesbismendD paren as S. Height —__| By Se ara ie 5 tytands are , or mari /omen employees only) Marital Status . Date of birth : Day 31. Mark of identification 12. Permanent Aiddress Village TaluliSub.aiv ne eee Ap sri sree Contingencies of the nominee! | ship with, nominee accumulation in the happening of which ‘or nominees the member Pind bopeil|@) 7 uetegaeee ty ey £2ch nomi bee some invalid 73 een eae 4 Relaionship of ie pousdian with th fs € nominee Date cd i ah ste dct ey Corporation hfe re ater bes read ie Thee uf | Signature or left hand shim { inpresson of the member been signed dy — Fhve been bad out him me fe “Agreenient to be executed by Members: on becoming S.member of the Fond shall execute an agreement in the. that have redd and unders Regions, 1967 and | sald Regulationa ee 2 -@ NOMINATION AXD DECLARATION FORM FOR UNEXEMPTED/EXEMPTEDESTABLISHMENT Declaration and Nomination Form under the Employees’ Provident Funds and Employees’ Pension Schemes (Paragraphs 33 and 61 (1) of the Employees’ Providen} Funds Scheme, 1952 and Paragraph 18 of the Employees’ Pension Scheme, 1971] Name (in block letters) Father's Name Date of Birth Sex Marital Status an rene Account Number 2 CPR A/C. NO. EPS. A/C NO. 7. Address (Permanent) Address (Temporary 8. (a) Date of joining of EPF Scheme, 1952 ; o ae Jjoining of EFP Scheme, 1971 : (© Dat of joining of EFP Scheme, 1995 | 1 PART - A (EPF) I hereby nominate the persons) / cancel the nomination made by me previously and nominate the person(s), mentioned below to receive the amount standing to my credit ia the Employees’ Provident Fund in the event of my death ~ 1 Namcjofthe | Address | Nominees | Dai of | Total amountor | U'the nominée isa nominee/ relationship | Birth share of | minor name and Nominees with the accumulations in | relationship and member Provident Fund to | address of the be paid to each | guardian who may ag nominee receive the ‘amount of nominee [eas 2 3 a 5 6 i 1.| “Certified that 1 have no family as defned in Provident Fund ___Scheme, 195: ~~ nomination should be dé as cancelled, “Certified that my father/mother is/are dependent ‘upon me. *Strike out whichever is not applicable. Para 2{g) of the Employees’UY @ Thereby furnish below particulars of the members of my family who would be PART - B (EPS) (Para 18) cligibie to receive widow/children pension in the event of my death Sr. | Name & Address of the family member | Date of Birth | Relationship with the No. ‘member 1 2 3 4 ‘Certified that I have no family as defined in Para 2 (vi) of the Employees’ Pension ‘Scheme, 1995 and should I acquire a family hereafter I sball furnish particulars thereon in the above form, {nde nominee te following persona fr seeing the fomtnly wid pension (ednissble under Para 160) a) () and Ui) of Employees anion Seteene 1098 ete vent of my death without leaving any lie fay ssomber for secels pension Tame & Address of the nominee Date of Birth Relationship with the z IB 2 member : aaa = ae 3 [ise E a le C jae i =a | oa ieee Date *Strike out] whichever is not applicable. _ t Signature or thumb impression, of the Subscriber CERTIFICATE BY EMPLOYER Certified that the above declaration and nomination has been signed/thumb impression before me by Shri/Smt. ere — empldyed in my establishment after he has read the entries and got confirmed by hirn. Signature of the employer or other Authorized officer of the establishment Place Dated|the Designation i Name f& Address of the factory/ Establishment Or rubber stamp thereof@ ANNEXURE-C © FORMNO.CPFI THE FOOD CORPORATION OF INDIA ‘T FROM FOR SUBSCRIPTION TO CONTRIBUTORY PROVIDENT FUND (RULE - 14) AGREEMEN The Board of Trustees, Food Corporation of india Contributory Provident Fund Headquarters, New Dethi time be prescribed). 1. Namne in Fat 2 Father’s Name 3. Nature of appointment 2 4. Dite of Joining Service Date of completion of probation 5. > Pale Wagers pe mont 7. Rate of subseripion (410) | pens OF WiTNEss DATE ae . SIGNATURE OR THUMB IMPRESSION DESIGNATION ADDRESS. | ‘The particulars furnished by thé applicants 4 conrgct. | (FOR OFFICE USE ONLY) _ OUNT NUMBER ASSIGNED MANAGER (A/C)YAOVNWW VEUV/YEOVNVW TYNOIOTY dO LNSWHSITEV1Sa 990 00p-fequunyyl # Gsaqy) a0uyyo 1e4OZ “eipu Jo uores0ds05 poo i ee “(4a9) saounin n9495 assy 24k Byer “01 papremiog sang uoneis ae 18} 05 ON SO/V ping “d'D Aue panio}1e unag tou aABUysey onoqe paLioltuaul (s)/eIo1g40 jeys pouym90 519} -:'N | ; “Paystuuny 2qoste Kew uojeousnON 312280 UI ON “IS PUL OV A410 BUEN “ON O/Y Jd PIO Alp 2049)SUB1 O04 Jo 9589 UI -ALON “GNAESHLOL : NOLLdIuosans. t NOISS¥ ON err LNSILNIOdSY e per | ptatosy ouanaioaa Oa NOLLYNS AQT HOAWVN | ON“IS | L SUVONCANEE nowsisiva ial i | A'd'D ‘ON WU | dd ‘194 3HL OL NOISSINGY YO. VIGNI JON | @- dUNLXINNY 2Juawysygerse ax) jo 1eoyo pesuoyne J8Ut0 10 Jefojdua aig jo aumjeUbg t saguiow e se patioiue 9q jou s! $6,853 84) J2pUN UO|sUEd, SL2r6 / HIV: wows; 2383 949 Jo “ON 909 z To z a r TIE IG-ON 30D OTS ; (Aue y'@ye0yNeD BWeYDS asojouZ) eure aroha aysssquewoy | snoweusj0 senajved @ ON sory |" wousnnue (uewom pourewjo aseo w) lamer yoo) ae ee pine joaea _lres| uayo sea | ewevspuecsn) sages] sels ound ewer ungooy | ig a= VIGNI JO NOLLYHOs4OD GOOS | Wawys);e153 a4) Jo SsasppY y aweN 2002"438N3030 Jo YUOW yj SuUNp puny Yod}sued-ouj0-dhysiequoW-40}-papiua-2afojdwe Jo WINER (oz ydesBeved) $661'3W3HOS NOISN3d S33AOTdWS 3HL (hve swuawysiqeiss peidwexg 103) (Sa) » ON WHOSForm No. 11 (New) Declaration Form (To be retained by the Employer for future reference) Employees’ Provident Fund Organization ‘THE EMPLOYEES’ PROVIDENT FUNDS SCHEME, 1952 (PARAGRAPH-34 & 57) & ‘THE EMPLOYEES’ PENSION SCHEME, 1995 (PARAGRAPH-24) Decuarati PERSON TAK. /LOYMENT IN AN ESTABLISHME CH EMPLOYEES’ PROVIDENT FUND ScHEM ‘AND/OR EMPLOYEES 1 (PLEASE GO THROUGH THE INSTRUCTIONS) 1) Name (Tm) Ma. | Ms. | Mins (PEAS TION 2) Dave oF BIRTH fo]o[Mys|v]y[yyy 3) FATHER’) Min HusBAND'S. NAME 4) RELATIONSHIP IN RESPECT OF (3) ABOvE [_ FATHER HUSBAND, (PLEASE Tex) 5) GENDER MALE FENALE | TRANSGENDER . (Puease Tice) (IF any), 6) MosILE NUMBER | 7), EMAIL ID (IF ANY) 8) WHETHER EARLIER A MEMBER OF THE EMPLOYEES’ PROVIDENT FUND SCHEME, 19527 (PLease Tick) YES NO : 9) WHETHER EARLIER A MEMBER OF THE EMPLOYEES! PENSION SCHEME, 1995? (Presse Tien) [ Yes NO IF RESPONSE TO ANY OR BOTH OF (8) & (9) ABOVE 1S YES, THEN MANDATORILY FILL UP THE PREVIOUS EMPLOYMENT DETAILS at (10,11812): Page 1 of 3110) THE DETAILS OF THE UNIVERSAL ACCOUNT NuMBER (VAN) OR PREVIOUS PF MEMBER ID: VAN i oR Previous PF MemBer 1D 11) Dare oF ExT For PREVIOUS "MemaeR ID (DD/MM/YYYY) 12) Region Cone | OFFice Cove | EstaausHMeNTID Extension | Account NuMBER (A) Ir scHeMe CERTIFICATE ISSUED FOR FREVIOUS EMPLOYMENT, THEN SCHEME CERTIFICATE NUMBER: (6) IF PENSION PAYMENT ORDER (PPO) ISSUED FOR PREVIOUS EMPLOYMENT, THEN PPO NUMBER: BL OTHER Derants 13) InTeRnaTional WoaKer (Puzase Tick) IF THE REPLY TO (13) ABOVE 15 YES, THEN ENTER THE Ys NO. 13(4) Coun oF ont (Please Tick) INDIA MENTION NAME (OF THE COUNTRY) 13(B) PASSPORT NUMBER 13(C) PASSPORT VALID FROM 14) EDucaTIONAL QuaLinicarion (PLEASE TI) 15) Manrrat STATUS (PLEASE TICK) 16) SPECIALLY ABLED (PLease Tick) DETAILS iN 13(A), 13(8) & 13(0): (OTHER THAN INDIA (IF YES, PLEASE D]O|M|™|YI¥DY|Y To DPO|"|™|Y]Y]Y|¥ NON SENIOR Post TECHNICA urTeRATE | araic | MATRIC | seconoarr | S™*PUNTE | Geaouate | POT | proressional. MARRIED | UNMARRIED | WiDOW/ WIDOWER | DIVORCE Ye No TF YES, Tick THE CATEGORY Locomorive visuat HEARING Page 2 of 317) KYC Devas [—_KYC DocunenT Tyee [NAME AS ON KYC DocuneNT NUMBER REMARKS, IF ANY Bank ACCOUNT-1* NPRVAADHAAR PERMANENT ACCOUNT Numaer (PAN) PASSPORT DRIVING LICENCE ELECTION CARD RATION CARD BSICGRD © Mandatory Field (NOTE: BANK ACCOUNT NUMBER (ALONG WITH IFSC CODE) IS MANDATORY. YOU ARE HOMEVER ADVISED TO PROVIDE AtL_KYC DOCUMENTS AVAILABLE WITH YOU IN ADDITION TO MANDATORY KYCS TO. AVAIL BETTER SERVICES. SELF-ATTESTED PHOTOCOPIES OF THE DOCUMENTS MUST BE ATTACHED WITH THIS FORM. ©. UNDERTAKING: |A._ CERTIFY THAT ALL THE INFORMATION GIVEN ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF. B._ INCASE, EARLIER A MEMBER OF EPF SCHEME, 1952 AND/OR EPS, 1995, (()_ LAVE ENSURED THE CORRECTNESS OF My UAN/ PREVIOUS PF MEMBER ID. (A) THis MAY ALSO BE TREATED AS MY REQUEST FOR TRANSFER OF FUNDS AND SERVICE DETAILS IF APPLICABLE FROM. THE PREVIOUS ACCOUNT AS DECLARED ABOVE TO THE PRESENT P.F. ACCOUNT. (THE TRANSFER WOULD BE POSSIBLE ONLY IF THE IDENTIFIED KYC DETAILS APPROVED BY PREVIOUS EMPLOYER HAS BEEN VERIFIED BY PRESENT EMPLOYER USING HIS DIGITAL SIGNATURE CERTIFICATE). (11D) 1 aw AWARE THAT I CAN SUBMIT MY NOMINATION FORM THROUGH UAN BASED MEMBER PORTAL. Dare PLACE: ‘SIGNATURE OF MEMBER DECLARATION BY PRESENT EMPLOYER | A THE MEMBER Mr./Ms./Mrs. HAS JOINED ON “AND HAS BEEN ALLOTTED PF MEMBER 1D B, _INCASE THE PERSON WAS EARLIER NOT A MEMBER OF EPF SCHEME, 1952 aND EPS, 1995: + (POST ALLOTMENT OF UAN) THE UAN ALLOTTED FOR THE MEMBER IS © PLEASE TICK THE APPROPRIATE OPTION: THE KYC DETAILS OF THE ABOVE MEMBER IN THE UAN DATABASE (HAVENT BEEN UPLOADED __ HAVE BEEN UPLOADED BUT NOT APPROVED HAVE BEEN UPLOADED AND APPROVED WITH DSC C. INCASE THE PERSON WAS EARLIER A MEMBER OF EPF SCHEME, 1952 AND EPS, 1995: + THE ABOVE MEMBER ID OF THE MEMBER AS MENTIONED IN (A) ABOVE HAS BEEN TAGGED WITH HIS/HER UAN/PRe vious Memaer ID AS DECLARED BY MEMER. + PLEASE TICK THE APPROPRIATE OPTION:~ THe KYC DETAILS OF THE ABOVE EMBER IN THE UAN DATABASE HAVE BEEN APPROVED WITH DIGITAL ‘SIGNATURE CERTIFICATE AND TRANSFER REQUEST HAS BEEN GENERATED ON PORTAL, (AS THE DSC OF ESTABLISHMENT ARE NOT REGISTERED WITH EPFO, THE MEMBER HAS BEEN INFORMED TO FILE PHYSICAL CLAIM (FORM-13) FOR TRANSFER OF FUNDS FROM HIS PREVIOUS ESTABLISHMENT. Dare: ‘SIGNATURE OF EMPLOYER WITH SEAL OF ESTABLISHMENT Page 3 of 3Instructions for filing up Declaration Form a. Form to be filled in the language of the form b. Each box, wherever provided, should contain only one character (alphabet /number Jpunctuation sign) leaving a blank box after each word. & The ktem-wise instructions to fill up the form are as follow. 1. Please tick the Title (Mr/Ms/Mrs) and write full name in the form in Item No 1. It is reiterated that each box should contain only one character leaving a blank box after each word. It may please be noted that the Title (Mr/Ms/Mrs) should not be entered again in the boxes provided to write full name. 2. Please provide Date of Birth in the form (00/MM/YY¥Y) in Item No 2. 3, Please provide Father's / Husband's Name in full in the form in Item No 3. it may please be noted that the Title (Mr/Sh.) should not be entered again in the boxes provided to write full name 4, Please tick the relevant box in item no 4 based on Item no 3, Tell the relationship ie Father or Husband 5. Please Tick the relevant Box in Item No 5 6 Please provide your mobile number on which formal communication can be established and necessary information can be provided through .M.S to the member in Item No 6. 7 Please provide e-mail id on which formal communication can be established and necessary information can be provided through e-mails to the member in Iter No 7. 8. Please tick ‘YES’ if you have previous membership of the Employees’ Provident Fund Scheme, 1952 otherwise ‘NO’ in Item No 8, which is a mandatory field 9. Please tick “YES' if you have previous membership of the Empfoyees’ Pension Scheme, 1995 otherwise ‘NO’ in Item No 9, which is a mandatory field if you have ticked ‘YES in any or both of (8) & (9) cbove, please follow points 10, 11, & 12 to fill up the previous employment details at item Numbers 10.11 &12, otherwise follow 13 onwards, This is very importgnt and should be entered with utmost care os. a number of services including taqging of various member IDs with VAN and its portability are dependent on these details. 10. Please fill Universal Account Number (UAN) Or Previous employment P.F. member 1D in Item No (10) « UAN is 12 digit number which has been allotted by EPFO and provided to the EPF oe member through employer. To check whether you have been allotted UAN againstyour PF member 1D, please go to the UAN Member e-sewa on EPFO website www epfindia.gov.in and click on Know your UAN status. ‘+ Previous employment P.F. member ID is to be furnished in the boxes as | Recion Cove | OFrice Cove | Esrasusniwenr ID | Extension | ACCOUNT NuweeR For instance, the number MH/BAN/12345/123 has to entered as [mH {BAN [12345 ——SS« 000 123 and the number MH/BAN/12345/A/123 has to enteredas ; Twa jean [2345 ‘008 123 11. Please fill Date of Exit (i.e, Date on which member has ceased to work in the previous establishment) for the previous employment in Item No. 11. 12, Please provide the details of Scheme Certificate in Item No. 12 (A) and Pension Payment Order in Item No. 42 (8), if the same have been issued to the member for the previous membership 13. Please tick the relevant box in Item No. 13. if you are international worker then fill the boxes 13(A), 13(8) & 13(C) ie. please provide country of origin In 13(A), Passport Number in 13(8) and validity period of Passport in 13(C) 14. Please tick the relevant Box for educational qualification in Item No. 14 15. Please provide marital Status by ticking the relevant Box in Item No. 15. 16. Please tick the relevant box for handicap status in item No. 16, If response to this item is YES, please tick the relevant category in the adjacent box 17. Please provide ‘Know Your Customer (KYCY details of all the available documents mentioned in this column as far as possible. Bank account Number with LFSC code is mandatory. Fill the name as on KYC with KYC Number and also the remarks in item No 17 Remarks column is to fill up the relevant details ie. .F.S.C. code in case of Bank account Number, ‘Valid up to’ date in case of Passport, date of expiry in case of driving license itis very important to note that KYC details are required to provide better services to the members and hence details of maximum number of documents should be provided in the Item No. 17. Please put your signature in the space provided with date and place. Please submit the filled up form to the present employer. The present employer is required to take necessary action as explained in detail on EPFO website under UAN services and fil up the necessary details with his signature, designation and seal in the space provided.